Safety vs. Autonomy
- All American adults have a constitutional right to choose how to live their lives, and that includes the right to refuse help. Authorities may intervene without consent only if the person lacks the capacity to make decisions and understand the consequences.
Assessing decision-making capacity is not straightforward, however. Cultural traditions or a manipulative leader may dictate personal choices. Moreover, you may take less seriously choices you think unwise. If a person does lack the capacity to decide, who has the right to say what is best for him? If he doesn't perceive that he is neglected, at what point do you tell him?
Dilemmas Concerning Caregivers
- Knowing how to approach caregiving depends on understanding the reasons for neglect. Spouses or family members may be too old, young or frail to cope, ignorant of needs, or busy with work and childcare. Agency or home-care staff may be overworked or undertrained.
Criticizing or reporting caregivers may alienate them, increase resistance or provoke retaliation against the vulnerable person. They may refuse to let you in the at-risk person's home, for example, or decline to join career-support groups for fear of censure.
Remember that a vulnerable adult's isolation may be deliberately self-inflicted as a way to avoid family as well.
Dilemmas About Own Role
- Investigating neglect may call your principles into question. You must allow for other people's values and preferences, for example for privacy, even when they differ from your own standards. You must also encourage adults to choose for themselves, even though they may be accustomed to dependency and want you to choose for them. Be aware of the different interests at stake: the person's welfare, family cohesion, the cost of services to health or municipal authorities -- your reputation. Try to clarify who has legal liability, in case, for example, you make caregiving arrangements that go wrong.
- State and federal laws set penalties for neglect, but variable prosecution levels may compromise your actions. Fear of litigation may affect your decisions or how much support you receive from your employer.
By saying that someone lacks decision-making capacity, you may win better care for them but erode their legal rights to self-determination. You may feel your duty is to uphold the law, or to question it where it fails to help at-risk individuals. You may have a legal duty to report neglect, but an ethical duty to help families cope better without government interference.
Possible Ways Forward
- Base your ethical decisions on principles such as respect for autonomy, confidentiality, professional standards and justice. You can offer information and opportunities without infringing on the right to choose; for example, a person may want to live alone but welcome chances to socialize. Try to promote empowerment over dependence, and mold strategies to individual circumstances. Small interventions may encourage compliance, whereas larger gestures may arouse antagonism.
Ask only essential questions -- people may wish to hold on to personal secrets.
Establish clear contracts for providing services to avoid conflicts of interest. Clear communication with health and social care professionals makes reporting neglect easier. Discussions with colleagues can help keep self-assessment realistic. Improved research, training and networking among professionals working with vulnerable adults is key to going forward.